Continued Inpatient Care Research Articles

Cardiac rehabilitation centers in Romania: Where are we now?

Purpose: In 2024, Romania is still facing a critical challenge with high cardiovascular disease mortality rates despite extensive research and policy initiatives. Our study sought to examine the actual state of cardiac rehabilitation in Romania by identifying the healthcare facilities that provide and deliver cardiac rehabilitation services. Methods: The research began with a comprehensive investigation into cardiac rehabilitation centers across Romania. This involved leveraging search engines to identify these facilities. Keywords like “cardiac rehabilitation”, “cardiovascular rehabilitation”, and “cardiac rehabilitation centers” were instrumental in pinpointing relevant information, which included names, geographical locations, and contact details of the centers. Upon identification of potential centers, our research team initiated direct engagement with these facilities via telephonic interviews. Results: The data collected in 2024 was compared to previous findings from a 2017 research report to evaluate the progress and impact of prevention efforts over time. While the number of cardiac rehabilitation centers has grown (69.2% increase in the nationwide count of cardiac rehabilitation centers/facilities), an uneven geographic distribution persists, exacerbated by disruptions during the COVID-19 pandemic. Among the cardiac rehabilitation centers identified, 23% are located in balneoclimatic resorts, but the majority of cardiac rehabilitation centers are located in Bucharest. Overall, 65.3% of all identified centers in Romania belong to the private healthcare sector. Among these private centers, 41.1% offer cardiac rehabilitation programs as continuous inpatient care, with durations ranging from 5 to 16 days. All cardiac rehabilitation centers are equipped with the necessary equipment to perform basic cardiological investigations as well as physio-kinesiological rehabilitative procedures, in addition to aerobic physical training (53.8%). In 33.3% of the identified centers, diabetologists and psychologists/psychotherapists are integral members of the multidisciplinary cardiac rehabilitation team, while only 19.2% of the centers include a dietitian/nutritionist. Regarding costs, there is significant variation depending on the geographical area. In Bucharest, a single rehabilitation session costs between 100 to 400 lei (20 to 80 €), and a rehabilitation program spanning 4-6 weeks can cost up to 3350 lei. Comparing costs identified in 2017, we have observed an increase ranging from 47% to 188% in 2024. Conclusions: Despite an increase in the number of cardiac rehabilitation centers, their prevalence remains inadequate to fulfill the demands of the population. Telerehabilitation emerges as a promising solution, with limited adoption in only one center. Cost variations across regions pose a barrier to patient participation. Our article proposes strategies including decision algorithms for personalized recommendations, expanding cardiac rehabilitation centers, and advocating for comprehensive cost reimbursement. The urgent need for collaborative efforts is emphasized, envisioning innovative solutions like mobile applications to foster a sense of community and optimize cardiac rehabilitation, ultimately improving cardiovascular health outcomes in Romania. Keywords: cardiac rehabilitation, telerehabilitation, cardiac rehabilitation centers, healthcare disparities, cardiovascular health

Discharge of infants with complex care needs from the neonatal intensive care unit : Ensuring continued inpatient care via the Bunter Kreis aftercare model

After discharge of premature infants with complex care needs from the neonatal intensive care unit, a care gap arises due to the transition from inpatient to outpatient care. Consequences can be rehospitalization, revolving door effects, and high costs. Therefore, following hospitalization or inpatient rehabilitation, the patient is intended to transition to sociomedical aftercare. The legal basis for this is formed by §43 paragraph2 of the Fifth Book of the German Social Code (SGBV). Over 80aftercare institutions in Germany work according to the model of the Bunter Kreis. The comprehensive concept describes possibilities for networking which exceed the services provided by sociomedical aftercare. Simultaneously, depending on their stage of development, young adults can receive aftercare according to this model up to their 27th year of life. The interdisciplinary team at the Bunter Kreis comprises nurses, social workers, social education workers, psychologists, and specialist physicians. The largest group of supported persons, with 6000-8000children per year, is comprised of premature and at-risk babies as well as multiple births, followed by 3000-5000children with neurologic and syndromic diseases. Other common diseases are metabolic diseases, epilepsy, and diabetes, as well as children after trauma and with rare diseases. Overall, the various diseases sum up to around 20clinical pictures. The current article presents the Bunter Kreis aftercare process based on case examples.

Breeching “The Goldilocks Zone”: Tetraplegia as a Rare Life-Altering Infective Complication of Adjuvant Breast Cancer Chemotherapy

Background: Adjuvant chemotherapy has been an integral component of breast cancer care for decades. Advances in supportive care have been made, but despite this, infective complications of therapy remain a significant toxicity concern. Case Presentation: A premenopausal patient presented to the emergency department during the third wave of the Covid-19 pandemic with sepsis after a second course of adjuvant docetaxel-cyclophosphamide chemotherapy. Overnight she developed tetraplegia. An urgent MRI cervical spine revealed a pre-vertebral, vertebral, and epidural abscess. This was treated with an emergency C4-C7 posterior cervical laminectomy and decompression. Her inpatient care involved a protracted ICU admission followed by rehabilitation. She remains tetraplegic and requires continued inpatient care over a year after presentation. Restricted pandemic-related hospital visiting has compounded the impact of her illness. Conclusion: Infective complications of adjuvant breast cancer chemotherapy remain an issue despite advances in supportive care. This case highlights the devastating, life-altering impact that these complications can have as emphasized by the inclusion of the patient’s perspective.

Pre-stroke disability and stroke severity as predictors of discharge destination from an acute stroke ward

Reliable prediction of discharge destination in acute stroke informs discharge planning and can determine the expectations of patients and carers. There is no existing model that does this using routinely collected indices of pre-morbid disability and stroke severity. Age, gender, pre-morbid modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) were gathered prospectively on an acute stroke unit from 1,142 consecutive patients. A multiclass random forest classifier was used to train and validate a model to predict discharge destination. Used alone, the mRS is the strongest predictor of discharge destination. The NIHSS is only predictive when combined with our other variables. The accuracy of the final model was 70.4% overall with a positive predictive value (PPV) and sensitivity of 0.88 and 0.78 for home as the destination, 0.68 and 0.88 for continued inpatient care, 0.7 and 0.53 for community hospital, and 0.5 and 0.18 for death, respectively. Pre-stroke disability rather than stroke severity is the strongest predictor of discharge destination, but in combination with other routinely collected data, both can be used as an adjunct by the multidisciplinary team to predict discharge destination in patients with acute stroke.

300. Continued inpatient care following elective anterior cervical discectomy and fusion increases the risk of 30-day readmissions and post-discharge complications

BACKGROUND CONTEXT With a shift toward value-based and bundled-payment models, identification of areas of cost and quality improvement will be required. Though abundant literature is present on the predictors of discharge destinations, few studies have studied the impact of discharge to an inpatient care facility (skilled-care or rehabilitation) on post-discharge outcomes following elective spine surgery. PURPOSE We sought to collate evidence using a large national multi-center surgical database to assess the clinical impact of continued post-discharged inpatient care (skilled care facility or inpatient rehabilitation unit) on 30-day complications, readmissions and mortality after elective anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING This was a retrospective study done using the 2015-2016 American College of Surgeons (ACS) – National Surgical Quality Improvement Program (NSQIP) database. PATIENT SAMPLE Current Procedural Terminology (CPT) codes for ACDF (CPT- 22551, 22552) were used to identify patients from the database. Only elective ACDFs being done for ≤3 levels were included in the study. Patients undergoing additional posterior cervical spine procedures (instrumentation, laminectomy, laminotomy, etc.) were excluded from the analysis. In addition, patients undergoing surgery for cervical fracture, malignancy and spinal deformity were also excluded. Finally data was filtered to remove for missing variables to prevent any confounding in analysis. Discharge disposition was defined as discharge to an inpatient care facility (skilled care or rehabilitation) vs home. Those patients being discharged to other destinations such as acute care hospitals, unskilled facilities and assisted living facilities were excluded from the analysis to ensure that the results are relevant to the objective of the study. OUTCOME MEASURES Thirty day postdischarge complications, reoperations, redmissions and mortality. METHODS Multivariate logistic regression analyses were used to assess for the independent impact of discharge to an inpatient care facility vs home on the odds of experiencing 30-day post-discharge complications, readmissions, reoperations and mortality, while controlling for preoperative, intraoperative and predischarge clinical factors and patient characteristics. RESULTS A total of 15,624 patients were finally included for analysis. A total of 459 (2.9%) patients were discharged to an inpatient care (skilled care or rehabilitation) facility. Age of ≥65 years, Black or African-American race, partially dependent or totally dependent functional health status, a LOS ≥3 days, a total operative time>150 mins, ASA grade>II and inpatient surgery were significant predictors for a discharge to skilled care/rehabilitation facility. Following adjustment for predischarge clinical characteristics, discharge to an inpatient care facility was an independent significant risk factor for renal complications (OR 8.22 [95% CI 1.84-36.7]; p=0.006) and 30-day readmissions (OR 1.63 [95% CI 1.09-2.42]; p=0.016). CONCLUSIONS Discharge to inpatient care facilities following elective ACDF is associated with higher odds of renal complications and 30-day readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimize the risk of complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Discharge to Inpatient Care Facility After Anterior Lumbar Interbody Fusion: Incidence, Predictors, and Postdischarge Outcomes

Despite a significant number of patients being discharged to inpatient care facilities after anterior lumbar interbody fusion (ALIF), the current literature remains limited regarding the predictors associated with a nonhome discharge and the impact of continued inpatient care in a facility on postdischarge outcomes. The 2013-2016 American College of Surgeons National Surgical Quality Improvement Program was queried using Current Procedural Terminology (CPT) codes for ALIF (CPT-22558) and additional level fusions (CPT-22585). Discharge to inpatient care facilities included discharge to skilled care facilities and/or inpatient rehabilitation units. Independent predictors of an inpatient care facility discharge were age older than 45 years (P < 0.001), female sex (P < 0.001), more than 10% body weight loss in the last 6 months prior to surgery (P=0.012), American Society of Anesthesiologists grade greater than II (P=0.005), undergoing a 2-level (P < 0.001) or more than 2-level fusion (P=0.017), a length of stay greater than 3 days (P < 0.001), and the occurrence of any predischarge complication (P < 0.001). After adjustment for differences in clinical and baseline characteristics between the 2 groups, discharge to an inpatient care facility after ALIF was independently associated with higher odds of any postdischarge complication (P=0.010), postdischarge wound complication (P=0.005), and postdischarge septic complications (P=0.011). No significant impact was seen on 30-day readmissions (P=0.943), 30-day reoperations (P=0.228), and 30-day mortality (P=0.913). With an increasing focus toward minimizing costs associated with postacute care, providers should understand the need of appropriate preoperative risk stratification and construction of care pathways aimed at a home discharge to reduce the occurrence and/or risk of experiencing postdischarge complications.

Discharge to inpatient facilities after lumbar fusion surgery is associated with increased postoperative venous thromboembolism and readmissions

BACKGROUND CONTEXTPostdischarge care is a significant source of cost variability after posterior lumbar fusion surgery. However, there remains limited evidence associating postdischarge inpatient services and improved postoperative outcomes, despite the high cost of these services. PURPOSETo determine the association between posthospital discharge to inpatient care facilities and postoperative complications. STUDY DESIGNA retrospective review of all 1- to 3-level primary posterior lumbar fusion cases in the 2010-2014 National Surgical Quality Improvement Program registry was conducted. Propensity scores for discharge destination were determined based on observable baseline patient characteristics. Multivariable propensity-adjusted logistic regressions were performed to determine associations between discharge destination and postdischarge complications, with adjusted odds ratios (OR) and 95% confidence intervals (CI). RESULTSA total of 18,652 posterior lumbar fusion cases were identified, 15,234 (82%) were discharged home, and 3,418 (18%) were discharged to continued inpatient care. Multivariable propensity-adjusted analysis demonstrated that being discharged to inpatient facilities was independently associated with higher risk of thromboembolic complications (OR [95% CI]: 1.79 [1.13–2.85]), urinary complications, (1.79 [1.27–2.51]), and unplanned readmissions (1.43 [1.22–1.68]). CONCLUSIONSDischarge to continued inpatient care versus home after primary posterior lumbar fusion is independently associated with higher odds of certain major complications. To optimize clinical outcomes as well as cost savings in an era of value-based reimbursements, clinicians and hospitals should consider further investigation into carefully investigating which patients might be better served by home discharge after surgery.

Alternative Payment Models Should Risk-Adjust for Conversion Total Hip Arthroplasty: A Propensity Score-Matched Study

BackgroundFor Medicare beneficiaries, hospital reimbursement for nonrevision hip arthroplasty is anchored to either diagnosis-related group code 469 or 470. Under alternative payment models, reimbursement for care episodes is not further risk-adjusted. This study’s purpose was to compare outcomes of primary total hip arthroplasty (THA) vs conversion THA to explore the rationale for risk adjustment for conversion procedures. MethodsAll primary and conversion THAs from 2007 to 2014, excluding acute hip fractures and cancer patients, were identified in the National Surgical Quality Improvement Program database. Conversion and primary THA patients were matched 1:1 using propensity scores, based on preoperative covariates. Multivariable logistic regressions evaluated associations between conversion THA and 30-day outcomes. ResultsA total of 2018 conversions were matched to 2018 primaries. There were no differences in preoperative covariates. Conversions had longer operative times (148 vs 95 minutes, P < .001), more transfusions (37% vs 17%, P < .001), and longer length of stay (4.4 vs 3.1 days, P < .001). Conversion THA had increased odds of complications (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.37-2.24), deep infection (OR 4.21; 95% CI 1.72-10.28), discharge to inpatient care (OR 1.52; 95% CI 1.34-1.72), and death (OR 2.39; 95% CI 1.04-5.47). Readmission odds were similar. ConclusionCompared with primary THA, conversion THA is associated with more complications, longer length of stay, and increased discharge to continued inpatient care, implying greater resource utilization for conversion patients. As reimbursement models shift toward bundled payment paradigms, conversion THA appears to be a procedure for which risk adjustment is appropriate.

Discharge to Inpatient Facilities After Total Hip Arthroplasty Is Associated With Increased Postdischarge Morbidity

BackgroundDischarge disposition accounts for significant variability in costs after elective total hip arthroplasty (THA). Therefore, institutions must evaluate the short-term clinical outcomes associated with postdischarge care options. The present study intends to characterize the associations between short-term morbidity after primary THA and discharge destination. MethodsPrimary elective unilateral THA cases performed for osteoarthritis were identified in the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2014. Propensity scores were used to adjust for selection bias in discharge destination, based on demographics, obesity class, preoperative functional status, modified Charlson comorbidity index, American Society of Anesthesiologists (ASA) class, and the presence of predischarge complications. Propensity-adjusted multivariate logistic regressions were used to examine associations between discharge destination and postdischarge complications, controlling for selection bias based on observable patient characteristics. ResultsAmong 54,837 THA cases included in the study, 40,576 (74%) were discharged home, and 14,261 (26%) were discharged to inpatient facilities. In multivariate propensity-adjusted analyses, patients discharged to continued inpatient care after THA were more likely to have septic complications (odds ratio, 2.34; 95% confidence interval, 1.58-3.45), urinary complications (1.51; 1.21-1.90), readmission (1.44; 1.29-1.59), wound complications (1.31; 1.09-1.57), and respiratory complications (1.93; 1.21-3.07). ConclusionDischarge to continued inpatient care following THA is associated with increased odds of postdischarge morbidity and unplanned readmission, after propensity score adjustment for predischarge characteristics. Additional research is needed on the impact of devoting resources toward facilitating discharge to home after THA.

Patient and Hospitalization Characteristics Associated With Increased Postacute Care Facility Discharges From US Hospitals.

The number of patients discharged to postacute care (PAC) facilities after hospitalization increased by 50% nationally between 1996 and 2010. We sought to describe payors and patients most affected by this trend and to identify diagnoses for which PAC facility care may be substituting for continued hospital care. Retrospective analysis of the National Hospital Discharge Survey from 1996 to 2010. Adult discharges from a national sample of non-Federal hospitals. Adults admitted and discharged to a PAC facility between 1996 and 2010. Our analysis includes 2.99 million sampled discharges, representative of 386 million discharges nationally. Patient demographic and hospitalization characteristics, including length of stay (LOS) and diagnoses treated. More than half (50.7%) of all patients discharged to PAC facilities were 80 years old or older in 2010; 40% of hospitalizations in this age group ended with a PAC stay. Decreases in LOS and increases in PAC facility use were consistent across payors and patient demographics. PAC facilities may be substituting for continued inpatient care for patients with pneumonia, hip fracture, and sepsis as these diagnoses demonstrated the clearest trends of decreasing LOS and increasing discharges to PAC facilities. The rise in discharges to PAC facilities is occurring in all age groups and payors, though the predominant population is the very old Medicare patient, for whom successful rehabilitation may be most unsure. PAC facility care may be increasingly substituted for prolonged hospitalizations for patients with pneumonia, hip fracture, and sepsis.

Costs of Home Versus Inpatient Treatment for Fever and Neutropenia: Analysis of a Multicenter Randomized Trial

For patients with cancer who have febrile neutropenia, relative costs of home versus hospital treatment, including unreimbursed costs borne by patients and families, are poorly characterized. We estimated costs from a randomized trial of patients with low-risk febrile neutropenia for whom outpatient care was feasible, comparing inpatient treatment with discharge to home care after inpatient observation. We collected direct medical and self-reported indirect costs for 57 inpatient and 35 outpatient treatment episodes of patients enrolled in a randomized trial from 1996 through 2000. Charges from hospital bills were converted to costs using Medicare cost-to-charge ratios. Patients kept daily logs of out-of-pocket payments and time spent by informal caregivers providing care. Dollar amounts were standardized to June 2008. Mean total charges for the hospital arm were 49% higher than for the home treatment arm ($16,341 v $10,977; P < .01). Mean estimated total costs for the hospital arm were 30% higher ($10,143 v $7,830; P < .01). Inspection of sparse available data suggests that payments made were similar by treatment arm. Inpatients and their caregivers spent more out of pocket than their outpatient counterparts (mean, $201 v $74; P < .01). Informal caregivers for both treatment arms reported similar time caring and lost from work. Home intravenous antibiotic treatment was less costly than continued inpatient care for carefully selected patients with cancer having febrile neutropenia without significantly increased indirect costs or caregiver burden.

Carvedilol reduced mortality and hospitalisation in severe chronic heart failure

(2001) N Engl J Med 344, 1651. Packer M, Coats AJ, Fowler MB, et al, . for the Carvedilol Prospective Randomized Cumulative Survival Study Group. . Effect of carvedilol on...

Long-Term Psychiatric Care Service and Coordination Gaps in Michigan's Publicly Funded Mental Health System

Abstract A multi-party planning effort examined long-term psychiatric care issues confronting Michigan's publicly funded mental health system. It was found that the state's Community Mental Health network primarily serves people experiencing mental illness, yet spends less than 45% of its funds on such individuals. The most pressing long-term psychiatric service gaps in Michigan were identified as: continuous inpatient care; housing; and wraparound service for minors. The greatest coordination difficulties involved mental health collaboration with: primary care; justice systems; substance abuse services; and schools. Recommendations were developed and advanced for dealing with the various gaps and other key issues.

Predictors of Success or Failure of Transition to Day Hospital Treatment for Inpatients With Anorexia Nervosa

Clinicians are under increasing pressure to transfer inpatients with anorexia nervosa to less intensive treatment early in their hospital course. This study identifies prognostic factors clinicians can use in determining the earliest time to transfer an inpatient with anorexia to a day hospital program. The authors reviewed the charts of 59 female patients with anorexia nervosa who were transferred from 24-hour inpatient care to an eating disorder day hospital program. They evaluated the prognostic significance of a variety of anthropometric, demographic, illness history, and psychometric measures in this retrospective chart review. Greater risk of day hospital program treatment failure and inpatient readmission was associated with longer duration of illness (for patients who had been ill for more than 6 years, risk ratio = 2.7), amenorrhea (for patients who had this symptom for more than 2.5 years, risk ratio = 5.7), or lower body mass index at the time of inpatient admission (for patients with a body mass index of 16.5 or less, risk ratio = 9.6; for those with a body mass index 75% or less than normal, risk ratio = 7.2) or at the time of transition to the day hospital program (for patients with a body mass index of 19 or less, risk ratio = 3.9; for those with a body mass index 90% or less than normal, risk ratio = 11.7). Inpatients with anorexia nervosa who have the poor prognostic indicators found in this study are in need of continued inpatient care to avoid immediate relapse and higher cost and longer duration of treatment.

The Evaluation of Mental Health Care Systems

While the demand for deinstitutionalization, strongly supported by the economic aspect of the issue, has resulted in a steep decline in the number of psychiatric beds in many Western countries, the evaluation of extramural psychiatric care has several difficulties, including that of proving effectiveness without experimental control of confounding influences. For a cohort of schizophrenic patients we investigated the impact of out-patient psychiatric treatment on length of stay in hospital and length of stay in the community. Out-patient care had a significant influence on readmission, but no effect on the length of in-patient treatment. While the average cost of community care was less than half that of traditional hospital care, in 6% of the patients this threshold value of continued in-patient care was exceeded. There also seems to be a non-monetary threshold, above which community care is no longer appropriate.

Mentally handicapped school leavers: where do they go?

This study presents the findings of a population-based study of severely educationally subnormal (ESN(S] and moderately educationally subnormal (ESN(M] school leavers in the borough of Trafford over a 4-year period. The ESN(S) school leavers attended adult training centres (ATCs), day centres or remained at home. Some later obtained part-time places at these centres. The numbers varied from year to year and the trends are examined. The numbers of ESN(S) pupils outside the borough were small and there were only 10 such leavers during the 4 years. Most of these (five) needed continuous inpatient care at the hospital attached to their residential school. Three of the 10 leavers were accommodated in a bungalow project in the borough. Almost half of the ESN(M) school leavers made use of government schemes to help youth unemployment. A large group progressed to further education, usually on the life skills course. The numbers entering open employment were small (23 out of 214) and of these the largest single number went into their families' businesses or worked in shops. The combined benefits of the special school, government youth training schemes and the courses of further education designed for the ESN(M) group are reflected in the small number of pupils who became unemployed after leaving school (13 out of 214). This proportion (6%) is less than the 8% total unemployed school leavers in the borough.